Sample Directive: Stating Instructions

Personal Directive

I, _____________________________, of ________________________, Alberta, do hereby declare that if I am unable to participate in decisions about my own future care, this Directive should be interpreted as a carefully considered expression of my wishes and directions.

If at such a time the situation arises in which there is no reasonable expectation of my recovery from severe physical or mental disability to a state of meaningful interaction with loved ones, family or friends, I direct that I be allowed to die and not be kept alive by medications or artificial means. In particular, I would like the following directions to be followed:

1. Measures of artificial life-support, in the above stated situation, that I refuse are:

   • Cardiopulmonary resuscitation and admittance into an intensive care unit.
   • Mechanical respiration when I cannot breathe by myself.
   • Prolonged gastric tube or intravenous feeding when I am indefinitely unable to eat through my mouth.
   • Antibiotic medication to treat or prevent infection.
   • Other: __________________________________________

2. I request to live my last days at home rather than a hospital, if my family agrees.

3. If any of my tissues or organs are healthy and useful for other people I give permission for all such donation, or as specified, during my life: _________________________________________________

   _________________________________________________

4. I do wish to have medication mercifully administered to me in order to avoid suffering even though this may shorten my remaining life.

Dated at ___________________ in the Province of Alberta, this ________ day of _________________, 20_____.